Basic demographics

In 2014, there were 523 members on the RANZCR membership database, 381 Fellows and 142 RO trainees. In 2018, there were 617 members: 480 fellows and 137 trainees. The breakdown by gender and response to the censuses is outlined in Table 1.

Workplace practice

In 2018, more male radiation oncologists were engaged in active clinical work compared to females – 174 (58.8%) versus 122 (41.2%) (P = 0.003). This discrepancy was even more apparent in 2014 with 165 (61.5%) of males in clinical work compared to 103 (38.5%) of females (P < 0.001). This represents a statistically significant change with decreasing P-value across the two census years. Of the ten respondents who were on leave in 2018, 9 of them were female. When reviewing the membership cohort in 2018, stratified by age, there were decreasing numbers of female ROs with increased age whereas there were trainee cohorts demonstrated more gender parity (Fig. 1a, b).

In 2018, there were overall more males working as RO consultants compared to females – 145 (58.9%) versus 101 (41.1%) in Australia and 26 (60.5%) versus 17 (39.5%) in New Zealand (P < 0.001). This was evident in the 2014 census where the majority of respondents working as RO consultants were male (62% male vs. 38% female) (P < 0.001). Conversely, women were more likely to work in locum positions with 4 of the 7 (57.1%) respondents answering this question being female.

Male respondents were more likely than female respondents to work in more than one practice in 2014 (P = 0.001); however, this was less evident in 2018 (P = 0.024). Male radiation oncologists were more likely to work in a combination of public and private work compared to females as reported in both the 2014 (P = 0.007) and 2018 (P = 0.015) censuses (Table 2).

Female fellows were more likely to work less than 1.0 full-time equivalent (FTE) compared to males as revealed in both the 2014 and 2018 census (P < 0.001). The 2018 census results demonstrated that males worked significantly higher actual work hours per week – an average of 45.5 h versus 38.3 h and also spent more hours per week on new cases compared to females (7.1 h vs. 6.1 h). On average, males self-reported seeing more new patients per year compared to females (268 vs. 208 new patients in 2014, 269 vs. 210 in 2018).

In regards to FTE preference among trainees, both the 2014 and 2018 census demonstrated that the majority of respondents who wished to work full time for the first 10 years of their careers were male (75.6% male vs. 23.5% female in 2018, 79.2% male vs. 20.8% female in 2014). The results also showed that the majority of respondents who wished to work part time were female (23.9% male vs. 76.1% female in 2018, 32.7% male vs. 67.3% female in 2014). Parental leave and family commitments were predominantly identified by trainees as the reasons for wishing to work less than full time in their early careers. Between the 2014 and 2018 census, there was an increase in the number of females working part time as demonstrated by density plots in Figure 2.

Additional postgraduate qualifications

The 2018 census revealed that male fellows were more likely to hold a postgraduate degree than females. This question was not as comprehensively addressed in the 2014 census, so we were unable to draw a direct comparison between the two census data sets (Table 3). Within the trainee cohort, there appeared to be a more equal balance of the number of male and female trainees who held an additional degree in 2018 compared to 2014 (Table 4).

Career pathway postattaining RANZCR fellowship

In both censuses, male respondents identified as being more likely to obtain a consultant or fellowship position, whereas female respondents were more likely to obtain locum roles. In 2018, 64% of males versus 36% of female moved directly into a consultancy role as opposed to 44.4% of males versus 55.6% of females who reported working as locums. In 2014, only female respondents (five in total) identified as being unemployed following obtaining their fellowship. There were 4 males and 2 females unemployed in 2018.

Leadership positions

Self-identified leadership positions

The 2018 survey asked respondents to self-identify any currently held leadership positions. The survey question provided some examples of such positions. Over half of the respondents identified as currently holding one or more leadership positions (56.1%). The number of males in self-identified leadership positions exceeded the number of females, 60.3% versus 39.4%. Figure 3 demonstrates the gender breakdown of the self-identified leadership positions among respondents. Note that this leadership question was not asked in the 2014 census.

TROG leadership positions

The following results were obtained from data provided directly by TROG and reflect the gender distribution among currently held leadership positions as of February 2021. We defined a ‘leadership position’ within TROG as the following: a member sitting on one of the Scientific Committees; the chair of each Scientific Committee, the Chair of the board, members of the board, current and past TROG trial principal investigators and the Chair and members of the TROG ASM Committee. The summary of this data is depicted in Figure 4.

Workforce

The data indicates that there is an evident male dominance across a number of measured workforce parameters. There are however some encouraging differences between the 2014 and 2018 survey results showing a potential shift towards gender equality. For example, a more evenly balanced ratio of male to female fellows emerged from the 2014 to the 2018 census and similarly, the trainee male to female membership ratio almost reaches equivalence in 2018. This is highlighted where the data is grouped according to age: a significant male dominance is seen within older age brackets, however there is close to equal gender representation among the 30–39 and 40–49-year old cohorts. A similar shift, albeit not as strong, has been identified overseas such as in the Canadian Association of Radiation Oncology workforce report in 2017 which demonstrated a rise in female radiation oncologists from 18% to 38% and female trainee numbers reaching parity at 50%.¹⁰ In contrast to this, the 2017 workforce report by American Society for Radiation Oncology (ASTRO) demonstrated that women comprised only 28.9% of all radiation oncologist and that the male: female ratio was more than or equal to 2:1 across all age brackets.⁹ This disparity was noted despite there being over 50% female representation among North American medical school graduates.⁹

Both censuses identified that male fellows were more likely to obtain a consultant position following election to Fellowship, while females were more likely to work in locum positions. Furthermore, the respondents who identified a period of unemployment postfellowship attainment were exclusively female, however the reasons for this unemployment were not accounted for. The specific reasons for this were not explored in either survey but may be multifactorial in nature relating to holding a capacity to work full time, research higher degree status, family/childcare commitments and/or potential employer or systemic biases.

Workload

Male radiation oncologists are more likely to work 1.0 FTE and higher actual work hours compared to their female colleagues. Furthermore, male radiation oncologists see more new patients per year. Interestingly, when this data set was specifically analysed for the New Zealand workforce, it was noted that while female radiation oncologists worked less than 1.0 FTE, they saw a similar number of new patients per year (n = 229.8) compared to their male colleagues (n = 240.4).¹¹ Neither survey explored the reasons why male radiation oncologists were more likely to work in a combination of public and private work compared to females. Potential contributing reasons for this may include a disparity in employment opportunities, financial incentives or more attractive leave and remuneration structures between public and private workplaces.

Higher education and academic endeavours

Male fellows were more like to hold research higher degrees than females. Since 2007, both editors in chief for JMIRO have been male, however the majority of associate editors were female. The data from TROG indicated that 68% of current or past clinical trial principal investigators have been male. Gender disparities within the RO academia sphere have been universally identified. For example, an analysis of a U.S. academic RO faculty found that females had significantly fewer publications and were less likely to obtain full professorship or hold chairperson positions.¹² This is not unique to RO – in academic medicine women are less likely to be full professors even after accounting for age, experience and research productivity measures.¹³ Our data did not explore formal university appointments or affiliations among fellows to understand if similar disparities exist in Australia and New Zealand. Among trainees, there does, however, appear to be a trend towards an equal number of male and female trainees who hold a higher degree.

Leadership

Our review highlighted a distinct gender gap existing within our specialty's leadership positions. The census data indicated that there was a higher proportion of males who self-identified in leadership positions compared to females and this was confirmed by the data supplied by the FRO and TROG. Faculty Council members, current and past deans and college committee chairs are dominated by male fellows and this is similarly the case for the TROG board members, board Chairs, Scientific Committee members and Chairs and Sub-specialty Working Party members.

This issue is not unique to Australia and New Zealand. In the past 60 years, there have only been 4 female presidents of the ASTRO.¹² Within U.S. RO academic programs, only 20% had a female program director and only 12% had a female chair.¹⁴ Of the 725 invited speakers for the ASTRO annual meeting between 2012 and 2016, only 27% of these were women.¹⁵ More broadly, across U.S. medical oncology, RO and surgical oncology academic programs, women composed of only 21.7%, 11.7% and 3.8% of chair positions, respectively.¹⁶ Within the medical education leadership sphere, there exists on authorship gender disparity with males authoring 69% of global oncology curricula.¹⁷

Future change

It is imperative to understand that despite the number of female trainee numbers reaching parity with their male counterparts, thus mitigating a ‘pipeline’ issue for fair gender representation, a number of barriers remain to achieving gender equality and equity in our specialty across all metrics. While direct and overt discrimination against women within our specialty and medicine is subsiding, unconscious bias still contributes to the glass ceiling.^{18, 19} Research in both the medical and corporate spheres have identified a number of strategies to mitigate unfair representation. Initiatives proposed include targeted mentorship of females by both male and female mentors, workplace training programs and educational modules to reduce gender bias and promoting female leadership representation at all levels.^18-20 Many such initiatives have been adopted and/or developed within RANZCR FRO.

On a broader societal level, shifting social expectations surrounding caregiving activities, providing funding support for childcare, having equitable parental leave policies and promoting flexibility within the workplace are all essential initiatives.^18-20 Ultimately, equal and diverse representation within our workforce and leadership will ensure that we are providing our patients and society with the most talented, qualified and inclusive cohort of radiation oncologists in Australia and New Zealand.

Study limitations

There are a number of limitations for this study. Firstly, the two census surveys were not designed to specifically interrogate gender differences within the surveyed workforce. While there were questions specific to leadership roles, this was not the primary focus of the census and the 2014 census did not include this subset of data. Furthermore, many of the RANZCR and/or TROG leadership position terms are for 2–3 years and it is possible that an individual's leadership role was not captured between the two census dates. We acknowledge the bias with self-reporting and in particular, the inherent gender bias that may result in under-reporting of leadership positions by females due to influences such as the impostor phenomenon (IP). This is a psychological concept where by “high-achieving individuals attribute their successes to external factors and are unable to internalize success”.²¹ Studies have shown that females are significantly more likely to report impostor beliefs than men.²¹ An attempt was made to analyse any difference between the two data sets collected between 2014 and 2018. However, we acknowledge that the census questions and style was not identical between these two years and any differences evident may be incidental findings rather than an emerging trend.

While our review captured some quantitative measures of gender inequity in our speciality, it does not delve into more subjective assessments of gender inequity. Research into this space has highlighted the challenges faced by women in RO - both as the result of unconscious bias or overt discrimination or harassment.²² One study by Jones et al.²² identified five common issues: gaining respect and exercising authority, obtaining resources and financial compensation, entering and advancing along the career pipeline, grappling with double standards and transcending internalized discrimination. Additionally, we did not tease out the various contributing factors to this inequity such as income discrepancy between public and private work, remuneration arrangements, social factors such as caring and family responsibilities or societal/governmental factors such as parental leave policies.³ Finally, our review does not include any data on race, ethnic diversity or members who identify with non-binary gender roles. We were therefore unable to explore whether any disparities exist for these cohorts.

In conclusion, this review is an important first exploration into gender diversity across Australia and New Zealand's RO workforce. Whilst our study indicates that gender disparities exist, there are some indications that this may be equalizing out over time.